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FROM FAX NO. Jan. 10 2003 11:24AM P2 <br />" <br />SFCONDARY CO` ES TIN&REPORT FORMI'AfNMENT'F <br />TESTING DATE: 1,:., —1 <br />I O"R INFORMATION <br />Name s: Ad r ¢ Phone# <br />Contact: <br />2,FACILTFY INFORMATION <br />Name: Address: Pbone# <br />Contact: <br />3JA)CAL, AGENCY ERFORMAnON <br />Namc: Adress; <br />lnv;ec(*rp-cscnv <br />3to(-k o n <br />Phon,0 <br />pax# ?c-),? 9 3 `13 3 <br />4. I Ezt UNQ CONTRACTOR INFORMA I ION <br />,*r <br />Namc. ..'OkA'Sor "n,!!- Lic.9 A Srsf 2-1 tr'? 1-4 <br />Phonog <br />5.SUMMAKY OF TEST RESULTS <br />Number of taAke-Number of piping Tuns_ -3 <br />Number of sumps tested, Numbcr of MC Boxes q <br />COMPONENT PASS FAIL CO NTS <br />Amular Tank 4 1 <br />gmime-9l <br />Annular Tank 47. <br />i Annul <br />Secondary Pipe #I <br />CMSO]irt(D-91 <br />Soc Pipe #2 wTaiy <br />Secondary Pipe #3 <br />GasolincoV <br />i P <br />Piping Stamp #3 <br />G-solin"7 <br />UDC: #1Di% <br />#1/2 <br />UDC 43 <br />Disp. 6 <br />5L <br />UDC #4 <br />D2- #7/8 <br />C, <br />Technician Sign�sturc: 4,'f <br />Date:. <br />